=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699360685
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAN FAMILY MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2021
-----------------------------------------------------
Last Update Date | 03/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11637 THE PLZ UNIT 45
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90650-3930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-318-0810
-----------------------------------------------------
Fax | 562-318-0811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11637 THE PLZ UNIT 45
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90650-3930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-318-0810
-----------------------------------------------------
Fax | 562-318-0811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BRENT HAN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 562-318-0810
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------